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8 Bicruciate Retaining Total Knee Arthroplasty
Table 8.1 Major BCR results reported in the literature
Reference Prosthesis # Knees Follow-up Results
Sabouret etal.
[2]
Goutallier etal.
[20]
Townley [9] Anatomic knee 532 2–11years 2% tibial loosening
Lavoie etal.
[21]
Pritchett [11] Anatomic knee 537 23years 94% survivorship, 5.6%
Beuchel and
Pappas [10]
Stiehl etal. [12] LCS BCR 324 14years 79% survivorship
Pelt etal. [22] BCR 107 3years 88% survivorship, 19
Eggenberger
etal. [23]
Christensen
etal. [24]
Alnachoukati
etal. [25]
Pritchett [26] BCRvsPCL 91 2–14years BCR vs. PCL 73.6%
Troelsen etal.
[27]
Singh etal. [28] BCR 133 2–2.87years 6 reoperations
Baumann etal.
[29]
Hermes 2C (Cloutier) 163 22years 82% survival, 4.3% aseptic
Hermes (Cloutier) 41 8years 2 loosenings
BCR 39 5years Equal to PS group, but 5
Low contact stress
knee, meniscal bearing
XP 195 5.2years 9.7% tibial loosening
BCR
Zimmer-Biomet
BCR 146 1–33months 1.4% revision
XPvsCR 23/22 2years No RSA diff.no PROM diff.
BCRvsUKAvsPS 34/34/34 18months FJS for BCR=UKA
46 12years 91% survivorship
66 2–32months 5% revision
loosening
89% excellent/good
adverse events in BCR
revised (mostly poly wear),
2 late ACL ruptures
revisions, 5 tibial loosening
94% neutral or higher
satisfaction
preferred BCR
1 BCR rev and 3
manipulations
96.2% survivorship
95
1. Improved kinematics
2. Increased ROM
3. More rapid recovery
4. Fewer complaints of clicking or patellar clunk
5. Better patient satisfaction
Disadvantages of the BCR TKA are as follows:
1. Design is only for a limited number of patients (selection is critical)
2. Surgical technique is demanding
3. Tibial loosening and/or tibial tray breakage can be a problem
4. Cruciate ligament degeneration after the BCR may lead to revision
5. Scarring around the ACL (cyclops lesion) can lead to loss of full extension
96
A. J. Tria and G. R. Scuderi
BCR TKA is not for all knees or all surgeons. The surgical technique is more
demanding than standard PCL sparing or PS TKA.If the correct knee is chosen, and
the surgical procedure is well monitored, the clinical results at midterm follow-up
are similar to other designs. Preservation of the presenting anatomy has always led
to excellent results in all orthopedic surgeries.
References
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Bone Joint Surg Br. 1971;53(2):272–7.
2. Sabouret P, Lavoie F, Cloutier JM.Total knee replacement with retention of both cruciate ligaments: a 22-year follow-up study. Bone Joint J. 2013;95-B(7):917–22.
3. Ranawat CS, Insall J, Shine J.Duo-condylar knee arthroplasty: Hospital for Special Surgery
Design. Clin Orthop Relat Res. 1976;(120):76–82.
4. Romanowski MR, Repicci JA.Minimally invasive unicondylar arthroplasty: eight year follow up. J Knee Surg. 2002;15(1):17–22.
5. Hurst JM, Berend KR.Mobile-bearing unicondylar knee arthroplasty: the Oxford experience.
Orthop Clin North Am. 2015;46(1):113–24.
6. Marmor L.Unicompartmental arthroplasty of the knee with a minimum of 10-year follow-up.
Clin Orthop Relat Res. 1988;228:171–7.
7. Riley D, Woodyard E.Long-term results of geomedic total knee replacement. J Bone Joint
Surg Br. 1985;67(4):548–50.
8. Sabouret P, Lavoie F, Cloutier M.Total knee replacement with retention of both cruciate ligaments: a 22-year follow-up study. Bone Joint J. 2013;95-B(7):917–22.
9. Townley CO. The anatomic total knee resurfacing arthroplasty. Clin Orthop Relat Res.
1985;(192):82–96.
10. Beuchel FF, Pappas MJ.Long-term survivorship analysis of cruciate -sparing versus cruciate
sacricing knee prostheses using meniscal bearings. Clin Orthop Relat Res. 1990;260:162–9.
11. Pritchett JW.Bicruciate-retaining total knee replacement provides satisfactory function and
implant survivorship at 23 years. Clin Orthop Relat Res. 2015;473(7):2327–33.
12. Stiehl J, Hamelynck KJ, Voorhorst PE. International multi-centre survivorship analysis of
mobile bearing total knee arthroplasty. Int Orthop. 2006;30:190–9.
13. Angerame MR, Holst DC, Jennings JM, Komistek RD, Dennis DA.Total knee arthroplasty
kinematics. J Arthroplasty. 2019;34(10):2502–10.
14. Noble PC, Gordon MJ, Weiss JM, Reddix RN, Conditt MA, Mathis KB.Does total knee
replacement restore normal knee function? Clin Orthop Relat Res. 2005;431:157–65.
15. Gunaratne R, Pratt DN, Banda J, Fick DP, Khan RJK, Robertson BW.Patient dissatisfaction following total knee arthroplasty: a systematic review of the literature. J Arthroplasty.
2017;32:3854–60.
16. Rolston L, Bresch J, Engh G, Franz A, Kreuzer S, Nadaud M, Puri L, Wood D.Bicompartmental
knee arthroplasty: a bone-sparing, ligament-sparing, and minimally invasive alternative for
active patients. Orthopedics. 2007;30(8 Suppl):70–3.
17. Rolston L, Siewert K.Assessment of knee alignment after bicompartmental knee arthroplasty.
J Arthroplasty. 2009;24:1111–4.
18. Steinert AF, Beckmann J, Holzapfel BM, Rudert M, Arnholdt J.Bicompartmental individualized knee replacement : use of patient-specic implants and instruments (iDuo™). Oper
Orthop Traumatol. 2017;29(1):51–8.
19. Tria AJ Jr. A contemporary bicruciate total knee arthroplasty. Semin Arthroplast.
2017;28:65–70.
8 Bicruciate Retaining Total Knee Arthroplasty
20. Goutallier D, Manicom O, Van Driessche S.Total knee arthroplasty with bicruciate preservation: comparison versus the same posterostabilized design at eight years follow-up. Rev Chir
Orthop Reparatrice Appar Mot. 2008;94(6):585–595.
21. Lavoie F, Denis A, Chergui S, Al-Shakfa F, Sabouret P.Bicruciate-retaining total knee arthroplasty non-inferior to posterior-stabilized prostheses after 5 years: a randomized, controlled
trial. Knee Surg Sports Traumatol Arthrosc. 2023;31(3):1034–42.
22. Pelt CE, Sandifer PA, Gililland JM, Anderson MB, Peters CL.Mean three-year survivorship
of a new bicruciate retaining total knee arthroplasty: are revisions still higher than expected? J
Arthroplasty. 2019;34:1957–62.
23. Eggenberger EE, Hurst JM, Morris MJ, Berend KR, Lombardi AV, Crawford DA.Midterm
outcomes of a bicruciate retaining compared with the bicruciate sacricing knee system. J
Arthroplasty. 2022;37:S2145–249.
24. Christensen JC, Brothers J, Stoddard GJ. Higher frequency of reoperation with a new
bicruciate- retaining total knee arthroplasty. Clin Orthop Relat Res. 2017;475:62–9.
25. Alnachoukati OK, Emerson RH, Diaz E, Ruchaud E, Ennin KA. Modern day bicruciateretaining arthroplasty: a short-term review of 146 knees. J Arthroplasty. 2018;33:2485–90.
26. Pritchett JW.Patients prefer a bicruciate-retaining or the medial pivot total knee prosthesis. J
Arthroplasty. 2011;26(2):224–8.
27. Troelsen A, Ingelsrud LH, Thomsen MG, Muharemovic O, Otte KS, Husted H.Are there differences in micromotion on radiostereometric analysis between bicruciate and cruciate-retaining
designs in TKA? Randomized controlled trial. Clin Orthop Relat Res. 2020;478(9):2045–53.
28. Singh V, Yeroushalmi D, Christensen T, Bieganowski T, Tang A, Schwarzkopf R.Early outcomes of a novel bicruciate-retaining knee system: a 2-year minimum retrospective cohort
study. Arch Orthop Trauma Surg. 2023;143(1):503–9.
29. Baumann F, Krutsch W, Worlilcek M, Kerschbaum M, Zeliner J, Schmitz P, Nerlich M,
Tibesku C. Reduced joint-awareness in bicruciate-retaining total knee arthroplasty. Arch
Orthop Trauma Surg. 2018;138(2):273–9.
30. De Windt TS, Van Laarhoven SN, Van Hellemondt GG.Bicruciate-retaining total knee arthroplasty: state of the art for the younger and active population? A systematic review and future
prospective. Appl Sci. 2022;12:10721.
31. Klaassen MA, Aikins JL.The cyclops lesion after bicruciate-retaining total knee replacement.
Arthroplast Today. 2017;3(4):242–6.
32. Winston BA, Jones J, Ries MD.Flexion contracture due to cyclops lesion after bicruciateretaining total knee arthroplasty. Arthroplast Today. 2019;5(4):442–5.
33. Pritchett JW. Patients prefer a bicruciate retaining or medial pivot knee prosthesis. J
Arthroplasty. 2011;26(2):224–8.
34. Zhou C, Peng Y, An S, Bedair H, Li G.Does contemporary bicruciate retaining total knee
arthroplasty restore the native knee kinematics? A descriptive literature review. Arch Orthop
Trauma Surg. 2022;142(9):2313–22.
35. De Faoite D, Ries C, Foster M, Boese CK.Indications for bi-cruciate retaining total knee
replacement: an international survey of 346 knee surgeons. PLoS One. 2020;15:e0234616.
https://doi.org/10.1371/journal.pone.0234616.
36. Boese CK, Ebohon S, Ries C, De Faoite D.Bi-cruciate retaining total knee arthroplasty: a systematic literature review of clinical outcomes. Arch Orthop Trauma Surg. 2021;141(2):293–304.
97
Chapter 9
Partial Knee Arthroplasties
ToddE.Bertrand, PatriciaR.Melvin, andAdolphV.Lombardi Jr
Historical Perspective
Partial knee arthroplasty, specically as it relates to the medial side of the knee joint,
has gained popularity for the treatment of end-stage anteromedial osteoarthritis
(AMOA) with multiple studies showing higher patient satisfaction, quicker overall
recovery, and lower risk of major medical complications compared to total knee
arthroplasty (TKA) [1, 2]. However, the initial reports at the advent of medial unicompartmental knee arthroplasty (UKA) were not as promising with results inferior
to total knee arthroplasty reported by multiple authors [3, 4].
Goodfellow and O’Connor were among the rst to report on a large case series
of medial unicompartmental knee arthroplasties with a modern prosthetic design. In
their study in 1988, they looked at 103 cases of the Oxford mobile bearing medial
unicompartmental arthroplasty system (Zimmer Biomet, Warsaw, IN) performed
between 1982 and 1985 with 76 medial and 27 lateral compartment replacements
with absence of the anterior cruciate ligament (ACL) not considered a contraindication. Absence of the posterior cruciate ligament (PCL) was not encountered. The
authors noted a strong association between failure of the arthroplasty and the state
of the ACL, whether intact or decient, particularly in the medial compartment,
with 4/5 (80%) of tibial components with aseptic loosening being in ACL-decient
knees. In addition, the only case of meniscal bearing dislocation noted in their series
was also in a knee that was noted to be ACL decient at the time of surgery. Their
conclusion was that medial UKA with a mobile bearing prosthesis in the setting of
ACL deciency failed 10 times more frequently (21.4% vs. 2.1%) than in those
knees with an intact ACL [5].
T. E. Bertrand · P. R. Melvin · A. V. Lombardi Jr (*)
JIS Orthopedics, New Albany, OH, USA
e-mail: LombardiAV@jisortho.com
Switzerland AG 2024
A. J. Tria Jr., G. R. Scuderi (eds.), The Cruciate Ligaments in Total Knee
Arthroplasty, https://doi.org/10.1007/978-3-031-75992-5_9
99© The Author(s), under exclusive license to Springer Nature
100
T. E. Bertrand et al.
The proposed mechanism of increased failure, specically aseptic loosening of
the tibial component, was two-fold. First, the increased force of the hamstrings
exerted as a secondary restraint to anterior tibial translation in ACL deciency is
countered by an equal force exerted from the quadriceps to avoid paradoxical exion of the knee. This increased muscle force is thought to increase contact pressures
in the joint and produce overloading, possibly leading to loosening. Secondly, if the
anterior tibial translation in ACL deciency is uncompensated by hamstring action,
the femoral component will edge load the tibial component, possibly leading to a
rocking-type phenomena and subsequent loosening. Interestingly, in the lateral
compartment, there was not an association between ACL deciency and failure of
lateral UKA.
In addition to the ACL status alone, Hernigou etal. in 2004 evaluated the effect
of slope of the tibial implant in mobile bearing medial UKA comparing ACL-intact
and ACL-decient knees. In 99 patients undergoing medial UKA, at the time of
implantation 50 knees had a normal appearing ACL, 31 knees had a damaged ACL,
and 18 knees had complete ACL deciency. In all, 77 knees had not been revised at
nal follow-up and mean anteroposterior (AP) tibial translation on weight bearing
lateral radiographs was 3.7mm with average posterior slope of the tibial implant of
4.3°. Five ruptures of the ACL were documented postoperatively after the index
procedure and in all of these knees the posterior slope was greater than or equal to
13°. Interestingly, in the 18 knees implanted with known ACL deciency, 11 were
un-revised at nal follow-up with average posterior tibial slope of less than 5°.
However, in the 7 knees that were revised with known ACL deciency, the posterior
tibial slope was greater than 8°. The conclusion was that posterior tibial slope of
greater than 7° should be avoided, particularly in ACL-decient knees if concomitant cruciate ligament reconstruction is not performed. This work was formative in
establishing early guidelines for the posterior slope of the tibial implant in both the
ACL-intact and ACL-decient knee for an optimal outcome [6].
Pathoanatomy
Anteromedial osteoarthritis, as described by Goodfellow and White, is the arthritic
pattern seen in an ACL-intact knee involving the anterior and central portions of the
medial tibial plateau [7]. Given that the ACL is intact the posterior tibial cartilage
remains intact secondary to the tibia not having excessive anterior translation. As
the knee goes into exion, the posterior femoral condyle rolls out of the central
defect on the tibia and up onto intact posterior tibial cartilage, thereby maintaining
the length of the medial collateral ligament and preventing a xed varus deformity
(Fig.9.1). However, the natural history of anteromedial osteoarthritis over time if
not treated can lead to functional ACL damage, potentially from notch osteophytes
that develop, thereby allowing anterior translation of the tibia and subsequent posterior tibial cartilage wear. This results in a more diffuse pattern of wear on the
medial tibial plateau and patients often complain of pain as a presenting symptom
9 Partial Knee Arthroplasties
Fig. 9.1 Schematic representation of anteromedial osteoarthritis of the knee showing intact posterior cartilage on the femur and tibia as the knee goes into exion
Fig. 9.2 Lateral
radiographs of ACL-intact
and ACL-absent knees
showing translation of the
femoral-tibial dwell point
posteriorly
101
rather than instability as the soft tissue contracture along with the development of
posterior and notch osteophytes provide a stability to the knee even in the setting of
ACL deciency (Fig.9.2).
In contrast, patients who otherwise have a normal knee without signs or symptoms of osteoarthritis who develop ACL deciency, traumatically or otherwise, and
do not undergo reconstruction will oftentimes have normal appearing tibial cartilage
in the anterior and central third with full thickness posterior wear secondary to anterior tibial translation. This pattern of osteoarthritis, known as posteromedial
102
T. E. Bertrand et al.
osteoarthritis (PMOA) is specically seen in ACL-decient and patients who do not
undergo reconstruction and who had a knee void of osteoarthritis prior to the injury.
In PMOA, the MCL also maintains its normal length because as the knee comes into
extension, the distal part of the femur rolls onto intact anterior and central cartilage,
thereby preventing medial contracture and xed varus deformity. Patients who present with this pattern of osteoarthritis tend to be younger tting with the traumatic
nature of ACL deciency and will tend to have instability as a main complaint rather
than pain. This possibly may be related to the patient’s desire to continue with high
impact activities that may involve cutting, pivoting, and changing directions, all
such motions that require a functionally intact ACL to perform well [8].
Criteria forUKA
Kozinn and Scott were the rst to develop a standardized set of criteria for assessing
patients’ candidacy for UKA.These criteria involved the exclusion of patients less
than 60years of age, weight greater than 82kg (180lbs), absence of a bone-on- bone
defect, anterior knee pain as the only presenting symptom, and cumulative angular
deformity greater than 15°. Inclusion criteria for UKA were physically active
patients with range of motion greater than 90°, a knee exion contracture less than
5°, minimal pain at rest, non-inammatory arthropathy, and an intact ACL [9].
Based upon these criteria, it has been estimated that only between 2 and 15% of
patients with knee osteoarthritis (OA) would be candidates for UKA [8].
Given the rigid selection criteria of Kozinn and Scott, the criteria set forth by the
Nufeld Orthopaedic Care Centre, referred to as the Nufeld criteria, for medial
mobile bearing UKA were less strict and felt to be more inclusive of a greater proportion of patients with knee OA.These criteria involved bone-on-bone medial cartilage loss, anteromedial osteoarthritis with preserved posterior cartilage/bone,
intact lateral cartilage, and a functionally competent ACL (Fig.9.3) [10–12]. Despite
the more relaxed nature of the Nufeld criteria compared to the original Kozinn and
Scott criteria, both include a functionally intact ACL as necessary for UKA, likely
owing to the substantial kinematic preservation afforded by an intact ACL.
More recent studies have looked at performing medial UKA in patients with
ACL deciency. Patient selection is key to achieving a good outcome, and an essential step in selection is to identify patients who are considered “copers” and “noncopers” [13, 14]. Patients with a history of traumatic ACL rupture without
reconstruction can develop posteromedial wear leading to varus deformity with
PMOA, which can be seen as posterior wear on the lateral radiograph. In contrast,
patients who develop AMOA with secondary ACL disruption over time secondary
to chronic anterior tibial translation and/or the development of notch osteophytes
will have both anteromedial and posteromedial OA patterns showing more diffuse
wear on lateral radiographs. When pain instead of knee instability is the main
9 Partial Knee Arthroplasties
Fig. 9.3 Tibial bone
specimen showing
anteromedial osteoarthritis
with preserved posterior
tibial cartilage
103
symptom and other criteria for medial UKA are satised, medial UKA combined
with or without ACL reconstruction is indicated. The decision on whether to pursue
ACL reconstruction concurrently with medial UKA revolves around patient age and
activity levels, with older patients or those with more sedentary lifestyles beneting
from xed bearing medial UKA without ACL reconstruction [15, 16].
Prosthetic Design
Unicompartmental arthroplasties can be broadly divided into mobile bearing and
xed bearing as it pertains to how the polyethylene component moves (mobile bearing) or locks (xed bearing) in relation to the tibial baseplate. Given the nature of
UKA, the cruciate ligaments located centrally in the intercondylar notch and tibial
eminences are not resected as part of the procedure. However, as it relates to the
cruciate ligaments, specically the ACL, preparation and placement of the tibial
baseplate are paramount. Whether performing xed or mobile bearing medial UKA,
the tibial baseplate preparation revolves around maximizing medial tibial plateau
coverage to distribute implant stresses across a broader area and decrease the risk of
medial tibial plateau fracture and subsequent baseplate subsidence. To accomplish
this, the vertical cut going anterior to posterior for baseplate preparation will involve
the medial aspect of the ACL tibial eminence without causing injury to intact ACL
bers (Fig.9.4). The design of modern-day tibial baseplates involves a metal lateral
wall that will lie ush against the anterior-posterior tibial bone cut and is recessed
along the proximal portion of the lateral vertical wall to avoid ACL irritation against
the metal implant (Fig.9.5).
104
Fig. 9.4 Intraoperative
image showing relationship
of ACL footprint ( ) to
the anterior-posterior cut
along the medial tibia for
baseplate preparation
T. E. Bertrand et al.
Fig. 9.5 Tibial implant of
Oxford medial partial knee
(Zimmer Biomet, Warsaw,
IN) with the lateral wall of
the implant recessed below
the proximal portion of the
tibia
9 Partial Knee Arthroplasties
105
Surgical Technique
Medial UKA withIntact ACL
The surgical technique for medial UKA will be outlined specically as it pertains to
the Oxford medial UKA (Zimmer Biomet, Warsaw, IN); however, the surgical principles, especially pertaining to tibial baseplate preparation, share similarities across
all UKAs.
The patient is placed supine on a regular table either with the leg straight or on a
leg-holder with the foot of the bed dropped to be perpendicular to the oor to help
to obtain maximal amount of exion for instrumentation and trialing. In the event
the UKA should be aborted in favor of a TKA in the hanging-leg position, the foot
of the bed can be raised and new drapes placed beneath to prevent contamination. A
thigh high tourniquet should also be used to help achieve a clean, dry bone-cement
interface if cementation is the chosen xation technique. After arthrotomy, the lateral compartment and ACL should be visually inspected to conrm that the UKA is
appropriate [17, 18].
Once the decision has been made to proceed with UKA, the medial tibia is
exposed with care taken to ensure that no release of the medial collateral ligament
is performed to avoid over correction beyond the pre-disease state of the knee. The
tibial resection guide is placed and should be set to take as minimal a tibial cut as
possible. The Oxford medial UKA (Zimmer Biomet, Warsaw IN) uses spoons that
can minimize bone cuts based on relation to the distal posterior femoral condyles.
The pins for the tibial guide should be placed away from the medial cortex and care
should be taken to not perforate the far cortex with the pin. Taking multiple passes
with the pin should be avoided to prevent stress risers and postoperative fracture [19].
The vertical tibial cut should be made with the saw blade perpendicular to the
exion/extension axis of the knee, coplanar with the medial tibial spine to maximize
tibial coverage. One should avoid raising the saw as this will lead to a deeper posterior vertical cut which can predispose to tibial plateau fracture [20]. Alignment outside of 6° or more of varus and any degree of valgus has been shown to place
increased stress on the tibial baseplate which may lead to early loosening or collapse. For similar reasons, excessive tibial slope should also be avoided [19]. Once
tibial preparation is completed, the tibial baseplate should be sized to the maximal
t possible without overhanging. Undersized tibial components may lead to
increased poly wear, and oversized tibial components may cause pain [20, 21]. By
closely opposing the tibial baseplate to the vertical cut, one may achieve additional
rotational stability.
Using an intramedullary alignment rod, the drill guide for the femoral component is connected by a coupler and centered over the femoral condyle. Drill holes
are then made through the femoral drill guide both for performing the posterior
femoral resection and for the use of spigots and reamers to balance the exion and
extension gaps. Once the posterior resection is completed, the distal femur is then